Secondary adrenal insufficiency physical examination: Difference between revisions
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{{ | {{Secondary adrenal insufficiency}} | ||
{{CMG}}; {{AE}} {{ADS}} | {{CMG}}; {{AE}} {{ADS}} {{IQ}} | ||
==Overview== | ==Overview== | ||
Patients with secondary adrenal insufficiency usually appear weak or cushingoid (if the cause is | Patients with secondary [[adrenal insufficiency]] usually appear [[weak]] or [[cushingoid]] (if the cause is [[glucocorticoid]] withdrawal). Physical examination of patients with secondary [[adrenal insufficiency]] is usually remarkable for [[cushingoid]] features like [[muscle weakness]], buffalo hump. [[Hypotension]] may or may not be present. The absence of [[hyperpigmentation]] is the hallmark and a distinguishing feature of secondary [[adrenal insufficiency]]. Also, the presence of [[visual field]] defects like [[bitemporal hemianopsia]] indicates a [[pituitary tumor]]. | ||
==Physical Examination== | ==Physical Examination== | ||
===Appearance of the Patient=== | ===Appearance of the Patient=== | ||
*Patients with secondary adrenal insufficiency usually appear weak and fatigued. | *Patients with secondary [[adrenal insufficiency]] usually appear [[weak]] and [[Fatigue|fatigued]]. | ||
*They may present with cushingoid features if there is any history of prolonged steroid intake. | *They may present with [[Cushingoid appearance|cushingoid features]] if there is any history of prolonged [[steroid]] intake. | ||
===Vital Signs=== | ===Vital Signs=== | ||
*Low-grade [[fever]] may be present | |||
*Low-grade fever | |||
*[[Tachycardia]] may be present | *[[Tachycardia]] may be present | ||
* | *[[Hypotension]]-less common <ref name="pmid3002680">{{cite journal |vauthors=Burke CW |title=Adrenocortical insufficiency |journal=Clin Endocrinol Metab |volume=14 |issue=4 |pages=947–76 |year=1985 |pmid=3002680 |doi= |url=}}</ref><ref name="pmid6276646">{{cite journal |vauthors=Stacpoole PW, Interlandi JW, Nicholson WE, Rabin D |title=Isolated ACTH deficiency: a heterogeneous disorder. Critical review and report of four new cases |journal=Medicine (Baltimore) |volume=61 |issue=1 |pages=13–24 |year=1982 |pmid=6276646 |doi= |url=}}</ref><ref name="pmid24503135">{{cite journal |vauthors=Charmandari E, Nicolaides NC, Chrousos GP |title=Adrenal insufficiency |journal=Lancet |volume=383 |issue=9935 |pages=2152–67 |year=2014 |pmid=24503135 |doi=10.1016/S0140-6736(13)61684-0 |url=}}</ref><ref name="pmid27271953">{{cite journal |vauthors=Cuesta M, Garrahy A, Slattery D, Gupta S, Hannon AM, Forde H, McGurren K, Sherlock M, Tormey W, Thompson CJ |title=The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study |journal=Clin. Endocrinol. (Oxf) |volume=85 |issue=6 |pages=836–844 |year=2016 |pmid=27271953 |doi=10.1111/cen.13128 |url=}}</ref> | ||
*No [[dehydration]] | |||
===Skin=== | ===Skin=== | ||
* [[Pallor]] may be present | *[[Pallor]] may be present | ||
* Bruises may be present | *[[Bruises]] may be present | ||
* | *No [[hyperpigmentation]] | ||
*Alabaster-coloured [[Pallor|pale skin]] | |||
*Loss of [[axillary]] or [[pubic]] hair | |||
===HEENT=== | ===HEENT=== | ||
* Extra-ocular movements may be abnormal | * Extra-ocular movements may be abnormal | ||
* Visual field defects can be seen such as [[bitemporal hemianopsia]] | * [[Visual field]] defects can be seen such as [[bitemporal hemianopsia]] | ||
===Neck=== | ===Neck=== | ||
*No [[Jugular venous distension]] | *No [[Jugular venous distension]] | ||
===Lungs=== | ===Lungs=== | ||
* Symmetric chest expansion | * Symmetric [[chest]] expansion | ||
* Normal [[tactile fremitus]] | * Normal [[tactile fremitus]] | ||
| Line 42: | Line 43: | ||
===Back=== | ===Back=== | ||
*Buffalo hump may be present | *[[Buffalo hump]] may be present | ||
===Neuromuscular=== | ===Neuromuscular=== | ||
*Patient is usually oriented to persons, place, and time | *Patient is usually oriented to persons, place, and time | ||
* Proximal/distal muscle weakness unilaterally/bilaterally may be present | * Proximal/distal [[muscle weakness]] unilaterally/bilaterally may be present | ||
* [[Bitemporal hemianopsia]] suggestive of cranial nerve VI compression by a pituitary tumor | * [[Bitemporal hemianopsia]] suggestive of [[cranial nerve]] VI compression by a [[pituitary]] [[tumor]] | ||
===Extremities=== | ===Extremities=== | ||
*Muscle atrophy may be present | *Muscle [[atrophy]] may be present | ||
* If associated with [[hypopituitarism]], patient can present with any one of the following physical signs according to the respective [[hormonal]] deficiency: | |||
{| class="wikitable" | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Hormonal deficiency | |||
! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Finding | |||
|- | |||
| rowspan="2" | '''ACTH''' | |||
|Acute | |||
| | |||
* [[Postural hypotension]] | |||
* [[Tachycardia]] | |||
|- | |||
|[[Chronic]] | |||
| | |||
* [[Anorexia]] | |||
* [[Weight loss]] | |||
* No [[hyperpigmentation]] | |||
|- | |||
|'''TSH''' | |||
| colspan="2" | | |||
* Slow movement and slow speech | |||
* Delayed [[relaxation]] of [[Tendon reflex|tendon reflexes]] | |||
* [[Bradycardia]] | |||
* [[Carotenemia]] | |||
* Coarse [[skin]] | |||
* Puffy face and loss of [[eyebrows]] | |||
* [[Periorbital edema]] | |||
* [[Macroglossia|Enlargement of the tongue]] | |||
* [[Diastolic blood pressure|Diastolic]] [[hypertension]] | |||
* [[Pleural Effusion|Pleural]] and [[Pericardial effusion|pericardial effusions]] | |||
* [[Ascites]] | |||
* [[Galactorrhea]] | |||
|- | |||
| rowspan="2" |'''Gonadotropins''' | |||
|Male | |||
| | |||
* Soft [[testes]] | |||
* Reduced [[muscle mass]] | |||
* Diminished facial and body hair | |||
* Fine facial wrinkles | |||
* [[Gynecomastia]] | |||
* Regression of [[sexual characteristics]] | |||
|- | |||
|Female | |||
| | |||
* [[Breast]] [[atrophy]] | |||
* Regression of [[sexual characteristics]] | |||
|- | |||
| rowspan="2" |'''Growth hormone''' | |||
|Children | |||
| | |||
* [[Short stature]] | |||
|- | |||
|Adults | |||
| | |||
* Decreased [[sweating]] and impaired [[thermogenesis]] | |||
* Reduced [[muscle mass]] and strength | |||
* Fine [[facial]] wrinkles | |||
* Increased central [[obesity]] | |||
|} | |||
==References== | ==References== | ||
| Line 59: | Line 131: | ||
[[Category:Endocrinology]] | [[Category:Endocrinology]] | ||
Latest revision as of 21:30, 15 November 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2] Iqra Qamar M.D.[3]
Overview
Patients with secondary adrenal insufficiency usually appear weak or cushingoid (if the cause is glucocorticoid withdrawal). Physical examination of patients with secondary adrenal insufficiency is usually remarkable for cushingoid features like muscle weakness, buffalo hump. Hypotension may or may not be present. The absence of hyperpigmentation is the hallmark and a distinguishing feature of secondary adrenal insufficiency. Also, the presence of visual field defects like bitemporal hemianopsia indicates a pituitary tumor.
Physical Examination
Appearance of the Patient
- Patients with secondary adrenal insufficiency usually appear weak and fatigued.
- They may present with cushingoid features if there is any history of prolonged steroid intake.
Vital Signs
- Low-grade fever may be present
- Tachycardia may be present
- Hypotension-less common [1][2][3][4]
- No dehydration
Skin
- Pallor may be present
- Bruises may be present
- No hyperpigmentation
- Alabaster-coloured pale skin
- Loss of axillary or pubic hair
HEENT
- Extra-ocular movements may be abnormal
- Visual field defects can be seen such as bitemporal hemianopsia
Neck
Lungs
- Symmetric chest expansion
- Normal tactile fremitus
Heart
Abdomen
Back
- Buffalo hump may be present
Neuromuscular
- Patient is usually oriented to persons, place, and time
- Proximal/distal muscle weakness unilaterally/bilaterally may be present
- Bitemporal hemianopsia suggestive of cranial nerve VI compression by a pituitary tumor
Extremities
- Muscle atrophy may be present
- If associated with hypopituitarism, patient can present with any one of the following physical signs according to the respective hormonal deficiency:
| Hormonal deficiency | Finding | |
|---|---|---|
| ACTH | Acute | |
| Chronic | ||
| TSH |
| |
| Gonadotropins | Male |
|
| Female |
| |
| Growth hormone | Children | |
| Adults |
| |
References
- ↑ Burke CW (1985). "Adrenocortical insufficiency". Clin Endocrinol Metab. 14 (4): 947–76. PMID 3002680.
- ↑ Stacpoole PW, Interlandi JW, Nicholson WE, Rabin D (1982). "Isolated ACTH deficiency: a heterogeneous disorder. Critical review and report of four new cases". Medicine (Baltimore). 61 (1): 13–24. PMID 6276646.
- ↑ Charmandari E, Nicolaides NC, Chrousos GP (2014). "Adrenal insufficiency". Lancet. 383 (9935): 2152–67. doi:10.1016/S0140-6736(13)61684-0. PMID 24503135.
- ↑ Cuesta M, Garrahy A, Slattery D, Gupta S, Hannon AM, Forde H, McGurren K, Sherlock M, Tormey W, Thompson CJ (2016). "The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study". Clin. Endocrinol. (Oxf). 85 (6): 836–844. doi:10.1111/cen.13128. PMID 27271953.